Patient is a 52-year-old Caucasian male, who was referred to outpatient rehab, following an elective right total hip arthroplasty. The patient had a history of traumatic injury to the hip requiring open reduction internal fixation and later, removal of all the hardware. The Patient developed osteoarthritis of the joint and progressively suffered from the hip pain this past 10 years. The Patient was modified independent with household and community ambulation using a single-point cane up to 500 feet on all level surfaces prior to surgery and patient performed household activities with marked difficulty due to the continuous perceived weakness he felt of the right hip accompanied by moderate to severe hip pain. Other significant medical history includes hypertension, migraine, and hyperlipidemia. Upon evaluation, the patient complained of difficulty with general mobility but required only minimal assistance with bed mobility and transfers, stand-by assist for ambulation of 150 feet using a front-wheeled walker, and contact guard while performing management of a flight of stairs with unilateral handrail. Patient reported minimal pain of 2/10 on the Visual Analog Scale (VAS) on the right hip at rest and an intermittent moderate pain during hip movements (5/10 on the VAS). Patient has been taking
10mg of Oxycodone orally every 5 hours and 500mg of Tylenol as needed for pain management.
The patient has tenderness over the incision area on the posterior aspect
MEDICAL HISTORY: Includes osteoarthritis, frequent urinary tract infections, hysterectomy 20 years ago, and some TMJ (The temporomandibular joint)
Katz, J. N., Wright, E. A., Polaris, J. J., Harris, M. B., & Losina, E. (2014, May 22). Prevalence and risk factors for periprosthetic fracture in older recipients of total hip replacement: a cohort study. BMC Musculoskeletal Disorders, 15(1), 1-9. http://dx.doi.org/10.1186/1471-2474-15-168Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Camera, I. M. (2011). Medical-surgical nursing: Assessment and management of clinical problems (8th ed.). St. Louis, MO: else
General: no history of weight change, fever or chills, weakness, fatigue, or change in appetite;
HISTORY OF PRESENT ILLNESS: Patient is a candidate for a total right hip revision. She has 2 units of directed packed red blood cells. It is not autologous. She does had Hepatitis B. She has arthrogryposis. She had a right total hip replacement many years ago by Dr. Dodd at the University of Miami. She has had multiple other surgical procedures as follows. A: She had bilateral foot surgery In the remote past. B: She had left hip surgery a year ago. C: She had right foot
Diagnostic procedure: a procedure performed to obtain information needed to make a diagnosis and treatment plan.
One afternoon a 67 year-old man presented to the emergency department of a small, rural hospital complaining of severe left leg and hip pain following a fall at home. The patient had no past history of falls. He had a history of impaired glucose intolerance, prostate cancer, hypercholesterolemia and hyperlipidemia. The patient’s current medications were atorvastatin and oxycodone for chronic back pain. The patient stated his pain was ten out of ten on a scale of one to ten with ten being the worst. The left leg appeared shorter than the right, edema was present in the calf, as was ecchymosis and he had limited range of motion. After an evaluation in triage by a registered nurse and a subsequent examination by the emergency department physician, a plan was established to sedate the patient using moderation sedation protocol and perform a manual reduction of the hip.
1000 Pt denied pain at this time and rate 0 on a scale of 0 to 10. Pt thanks me a lot for pain medication I gave her. Instruct the pt to report her pain early before it get worse so I can give pain medication. Pt verbalized understanding of the teaching. No sign of distress or discomfort at this time. Will continue to monitor………L.Gotora
HPI: S.J. is a 67 y/o Caucasian male with a history of left hip pain for two years. He has difficulty walking due to left hip pain and utilizes a cane, can walk five blocks, climbs stairs leading with the right leg. He denies any surgeries on the left lower extremity. He sought physical therapy, but he does not feel that it is improving his pain but does believe it is improving his strength. He is scheduled for a left total hip arthroplasty due to the progression of severe osteoarthritis of the left hip as confirmed by a pelvic x-ray and MRI of the lower extremity without contrast. S.J. has taken various medications that are listed on the current medication section of this note.
Patient reports left knee pain history of MVA in 2009 and injured left knee. Patient also reports tooth ache 4/10.
The patient is a 74-year-old female who tells me she did see Dr.[____] and she did get a shot into her hip. She states symptoms are "1000 times better". She does tell me he was done ultrasound and thought she might have a [____] tear, which at this point, if this does not work, she will need likely to have a hip replacement, as he did not think this is fixable at her age.
According to Goodman and Fuller (2009) Osteoarthritis is divided into 2 classifications: Primary and secondary. Primary OA is a disorder of unknown cause which in the cascade of joint degeneration it is believed to be a related defect in the articular cartilage. Secondary OA has a known cause, which may be trauma, infection, hemarthrosis, osteonecrosis, or some condition Primary Osteoarthritis (OA) is the most common joint disorder in the world and often affects the knee and hip joints (Rubak, Svendsen, Soballe, & Frost, 2013). For patients with primary hip OA, pain and disability are the most important indications for total hip replacement (THR) (Rubake et al., 2013, p.486) Primary symptoms of OA include joint pain, stiffness, and limitation of movement. Disease progression is usually slow but can
A twist on the "patient's perspective" approach is to describe a time when medicine failed to save or heal someone close to you. The purpose of this tactic would not of course be to rail against the medical profession, but rather to show how a disappointing loss inspired you to join the struggle against disease and sickness.
Mr. Tovar reported no pain currently in the affected left hip, but noted that when twisting or performing awkward movements he will experience discomfort. Mr. Tovar opined that the left hip injury was a result of repetitive use while performing his usual and customary duties as warehouse person for Southern Wine and
Current medications: Prescribed Antacids, Nexium, q24h, or when pain is severe, Tylenol 500 mg, PO, q12h.
DN is a 68 year old Caucasian male who lives in Pomona, Missouri. On September 14, 2009, DN underwent a scheduled left total knee arthroplasty at Baxter County Regional Medical Center. A consultation appointment about a total knee arthroplasty was scheduled when DN had increasing pain in his knees while doing chores and working on his dairy farm. The increasing pain DN was having been due to a history of osteoarthritis and the wear-and-tear on his joints throughout his life, no specific injury was noted. Depending on the outcome of the left knee, DN was consulted on having his right knee done in the future